C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 410—SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS › Subpart A—General Provisions

42 C.F.R. § 410.3

Scope of benefits

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(a) Covered services. The SMI program helps pay for the following:

(1) Medical and other health services such as physicians' services, outpatient services furnished by a hospital or a CAH, diagnostic tests, outpatient physical therapy and speech pathology services, rural health clinic services, Federally qualified health center services, IHS, Indian tribe, or tribal organization facility services, and outpatient renal dialysis services.

(2) Services furnished by ambulatory surgical centers (ASCs), HHAs, CORFs, and partial hospitalization services and intensive outpatient services provided by CMHCs.

(3) Other medicial services, equipment, and supplies that are not covered under Medicare Part A hospital insurance.

(b) Limitations on amount of payment. (1) Medicare Part B does not pay the full reasonable costs or charges for all covered services. The beneficiary is responsible for an annual deductible and a blood deductible and, after the annual deductible has been satisfied, for coinsurance amounts specified for most of the services.

(2) Specific rules on payment are set forth in subpart I of this part.

[51 FR 41339, Nov. 14, 1986, as amended at 57 FR 24981, June 12, 1992; 58 FR 30668, May 26, 1993; 59 FR 6577, Feb. 11, 1994; 66 FR 55328, Nov. 1, 2001; 75 FR 73613, Nov. 29, 2010; 88 FR 82177, Nov. 22, 2023]
Notes of Decisions
Cited in 5 cases, 1997–2018 · leading case: Floyd Wood v. Tommy G. Thompson, . As Sec'y of the Dep't of Health & Human Servs., 246 F.3d 1026 (7th Cir. 2001).
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Floyd Wood v. Tommy G. Thompson, . As Sec'y of the Dep't of Health & Human Servs., 246 F.3d 1026 (7th Cir. 2001). “§§ 1395j to 1395w-4, 1395x(s); 42 C.F.R. § 410.3 . Part B does not provide reimbursement for dental services.”
GCI Health Care Centers, Inc. v. Thompson, 209 F. Supp. 2d 63 (D.D.C. 2002). “§ 1395 , 42 C.F.R. § 410.3 . Medicaid, Title XIX of the Social Security Act, is a joint federal/state insurance program providing medical coverage for medically and categorically needy persons.”
Total Renal Labs., Inc. v. Shalala, 60 F. Supp. 2d 1323 (N.D. Ga. 1999). “§§ 1395k, 1395j and 1395x(s), 42 C.F.R. § 410.3 . Part B primarily pays for “medical and other health services,” which is defined in the Medicare Act to include (among other services) physician services, services incident to physician services, home dialysis supplies and…”
United States ex rel. Crockett v. Complete Fitness Rehab. (6th Cir. 2018). “See 42 C.F.R. § 410.3 . Part B will pay for rehabilitation services at a facility like Complete Rehab, but its benefits are more limited than those available under Part A.”
Tsoutsouris v. Shalala, 977 F. Supp. 899 (N.D. Ind. 1997). “§ 1395j-1395w-4, 1395k, 1995x(s); 42 C.F.R. § 410.3 . Generally, Medicare limits its coverage to expenses which are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
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